Yesterday,
the Centers for Medicare and Medicaid Services (CMS) issued interim guidance on how the manual
medical review process will be implemented in 2013 for outpatient therapy
claims that exceed $3,700.

From
October 1, 2012, through December 31, 2012, CMS used a prior approval process
at $3,700 under which providers would submit a request to their Medicare
Administrative Contractors (MAC) for approval of up to 20 visits. With the
request, providers would include information from the patients' medical record
(eg, progress reports, daily notes, plan of care) to support the need for the
additional visits.

For
2013, CMS has replaced the prior approval process with prepayment review, at
least for the interim. Under prepayment review, when the patient reaches $3,700
in outpatient therapy services, the MAC will send the provider an additional
development request (ADR) asking him or her to submit documentation so that the
MAC can determine whether the services are medically necessary. Typically under
Medicare, MACs have 60 days to make a determination. However, CMS has requested that with regard to the therapy cap manual medical review process, MACs decide within 10 days of receipt of the documentation whether the services exceeding
$3,700 will be paid.

CMS
currently is working on a long-term strategy for the manual medical review
process.

Physical
therapists should consult their MACs' websites for specific information about
submitting documentation in response to an ADR.

Comments

If the MAC sends a request for prepayment review when the payment for PT/Speech is at $3,700, the patient will could have an extended wait to find out if their therapy will be covered. The billing is submitted, it takes 2 weeks or more for payment and for the recording of the amount paid for services. Then the documentation is requested by mail that takes a couple of days and then up to a 10 day wait for determination. The patient could be 3 or 4 weeks without therapy. If the patient has a new condition or acute injury this wait doesn't serve the patients need for immediate care. If therapy is prescribed to treat a patient's medical condition, it could be similar to asking the patient to wait a few days to fill their medication prescription to be sure it will be paid for by Medicare. The patient may suffer during the wait and their health decline during the wait. There are some people that have a series of unfortunate events within 1 calendar year: a total knee replacement followed by a stroke and then later in the year pneumonia. It is hard to see why a person shouldn't have the same access to therapy for all of these events.

Posted by Laura Bennetts
on 2/22/2013 8:50 PM

The ruling that came out of CMS regarding the MMR process is disheartening at best. I work in the LTC setting and see residents who deserve and need therapy services in order to maximize their quality of life. These residents health conditions can change almost instantly. Without prompt attention these people will suffer due to a poor government mandated process that doesn't take their health into account. This ruling will at best guarantee a delay in many people getting the services they need and at worst will prevent services and delay healing of their particular issue. I ask that CMS reconsider their announcement and at minimal change the prepayment review to a post payment process. As a provider we cannot afford to continue to deliver services, pay therapist for their skilled services to deserving patients without knowing that we will be promptly reimbursed. Please consider the patient first here and consider changing your ruling.

Posted by Greg
on 2/24/2013 10:01 PM

This article was updated at 4:00 pm 2/26/13.

Posted by News Now staff
on 2/26/2013 4:17 PM

This delay in pt/speech can be terrible for the patient. Not only making their treatment delayed but their condition worse and causing them to have to have longer treatment. At the present my Rx for magxalt is limited to two Rxs per month. This is not enough because I have daily headaches that can get out of control to limit this med only makes me need Rx pain killer more and could even cause me to have a stroke which would be much more expensive to pay for than the the magxalt.